Intravitreal silicone oil droplets following pegaptanib injection

Silicone oil droplets in the vitreous after intravitreal injections: review of literature with clinical examples

Currently, intravitreal injections are firmly in the lead as a drug delivery method for treatment of a wide range of eye diseases. With the accumulation of clinical material, knowledge about the complications and side effects of this technique is expanding. One of the undesirable phenomena that has been actively studied recently is the ingress of silicone oil droplets from single-use syringes and needles used to perform the procedure into the vitreous cavity of patients eyes. The analysis of the results of original studies on this issue is carried out, and the currently available practical recommendations aimed at reducing the risk of this complication are presented. The article is illustrated with original clinical examples. It can be concluded that the penetration of silicone oil into the eye cavity during intravitreal injections is an urgent problem of modern ophthalmology that requires further investigation and solution.

Observation of Silicone Oil Within the Vitreous and Sclera Following Intravitreal Administration of Biotherapeutics Using Insulin Syringes in Cynomolgus Monkeys

Silicone oil droplets have been reported in the eyes of human patients following intravitreous (IVT) injections with several marketed biotherapeutic products. Intravitreous administration of a novel biotherapeutic in a 14-week cynomolgus monkey study using insulin syringes was associated with 2, non-test-article-related phenomena: "vitreous floater/clear sphere" on indirect ophthalmoscopy and intrascleral "foreign material near injection track" on histopathology. Retrospective analysis of 81 other preclinical studies of IVT administration of novel biotherapeutics found a greater frequency of clear spheres in monkey IVT studies using insulin syringes and formulations containing polysorbate. We were able to correlate microscopic findings of clear circular to oval areas in the sclera near the injection track with an energy-dispersive X-ray spectroscopy (EDS) signal for silicon at the same location in the sclera. These observations provide further evidence that silicone lubricant in insulin syringes/needles is the source of clear spheres noted in the vitreous and foreign material noted near the injection track in the sclera. Although considered inert and toxicologically insignificant, silicone deposition within the eye should form part of the risk-benefit equation in a clinical setting.

LARGE SILICONE DROPLETS AFTER INTRAVITREAL BEVACIZUMAB (AVASTIN)

PURPOSE

Despite its off-label status, intravitreal bevacizumab is the most commonly used intraocular anti-vascular endothelial growth factor agent. Regulation of compounding pharmacies has recently increased to make compounded pharmaceuticals safer. Despite these changes, a marked increase in symptomatic, large silicone oil droplets following intravitreal bevacizumab injections was noticed.

METHODS

Retrospective chart review was performed. Within a single private practice, patients who were noted to have large or symptomatic silicone oil bubbles after an intravitreal injection were reviewed.

RESULTS

A recent, dramatic increase in the incidence of large or symptomatic silicone oil droplets was noted, with 23 cases noted in the past 5 months, compared with 1 in the previous decade. Patients frequently noted a circular floater consisting of a dark ring surrounding a bright central area immediately following an injection of intravitreal bevacizumab. All bevacizumab injections were from single-piece insulin syringes. B-scan ultrasonography produced a very characteristic reverberation pattern. No inflammation or visual acuity loss was noted because of the droplets; however, some patients were annoyed enough to consider vitrectomy.

CONCLUSION

Patients should be carefully evaluated for this possibility, and the characteristic symptom of a round floater consisting of a dark ring surrounding a bright center, and the prominent reverberation pattern on B-scan ultrasonography may help increase detection. Changes in consent forms and discussion of this possibility are indicated while investigation into the cause of this increased incidence continues, especially if one is administering bevacizumab via the one-piece insulin syringes commonly used by compound pharmacies.

Silicone oil droplets in repackaged anti–vascular endothelial growth factors for intravitreal injections: In search of the main source of contamination

Introduction:

Repackaging of anti–vascular endothelial growth factors in polypropylene syringes lubricated with silicone oil for intravitreal use is associated with the presence of intravitreal silicone oil droplets. The objective of this study is to assess how the use of silicone-free syringes (for storage and/or administration) would reduce the amount of silicone oil droplets in the product to be administered.

Methods:

Two 16 mL vials of bevacizumab were repackaged at the compounding pharmacy to obtain four sets of product, each consisting of three 1.2 mL tubes of the drug repackaged in different ways. Set A was repackaged according to routine practice, that is, the drug was placed into 1 mL siliconized syringes and 60 µL aliquots were extracted with 0.5 mL insulin siliconized syringes until reaching 1.2 mL. In set B, a 1-mL silicone-free syringe was used, followed by a 0.5 mL siliconized syringe. In set C, only 0.5 mL siliconized syringes were used. In set D, only the 1-mL silicone-free syringe was used. Micro-Flow Imaging technology was used for quantifying silicone oil droplet–like particles below 25 µm.

Results:

Silicone oil droplet–like particles were absent in set D. Set C had the highest average frequency of these particles, which was much lower in sets A and B. Set B had the lowest frequency.

Conclusion:

0.5 mL insulin syringes with staked-in needles used for supplying the product seem to be the main source of silicone oil contamination in repackaged anti–vascular endothelial growth factors. Silicone-free insulin syringes with staked-in needles would be strongly recommended for supplying anti–vascular endothelial growth factor intravitreal injections from compounding pharmacies.

Silicone Oil Droplets are More Common in Fluid From BD Insulin Syringes as Compared to Other Syringes

Purpose:

During 2016 and 2017, numerous retina specialists reported silicone oil droplets after intravitreal injection, primarily associated with insulin syringes with a fixed needle. By contrast, adverse events were relatively rare for tuberculin syringes. We hypothesized that fixed-needle syringe injections have more silicone droplets due to the lack of dead space at the syringe–needle junction.

Methods:

Fluid from Becton Dickenson (BD) insulin syringes, BD tuberculin syringes, Henke Sass Wolf (HSW) insulin syringes, and HSW silicone-free syringes was examined microscopically for silicone oil droplets. Fluid was sampled at the beginning, middle, and end of injection; and droplets were photographed and quantified.

Results:

Silicone oil droplets were identified in 30% of the BD insulin syringes, measuring 0.9 ± 0.2 mm3; no oil droplets were found in BD tuberculin syringes or HSW silicone-free syringes (analysis of variance, P < .05). All 6 samples with silicone oil droplets were from the end of injection (full depression of the plunger), while samples from the beginning and middle of injections did not have droplets. Challenging syringes with extra silicone oil resulted in increased droplets for fixed-needle syringes (but not for syringes with detachable needles).

Conclusion:

Significant silicone oil droplets were present in BD insulin syringes and were expressed at the end of injection (with plunger depressed maximally), supporting the hypothesis that insulin syringe injections have more droplets due to the lack of dead space where the plunger meets the hub of the needle. However, there are additional factors such as the amount or type of silicone lubricant in a syringe.

Local and systemic complications after intravitreal administration of anti-vascular endothelial growth factor agents in the treatment of different ocular diseases: a five-year retrospective study

PURPOSE

To observe the frequency of complications in patients undergoing intravitreal anti-VEGF injections for different ocular diseases in a five-year period.

MATERIALS AND METHODS

Charts of patients receiving intravitreal anti-VEGF were retrospectively reviewed. Out of 1173 eyes, 762 were treated with bevacizumab, 382 with ranibizumab, and 29 with pegaptanib. Data recorded included demographic information, clinical findings, total injections received, and info about the onset of adverse effects.

RESULTS

12.86% of the eyes treated with bevacizumab presented side-effects, while ratings in the ranibizumab and pegaptanib groups were 15.97% and 20.69%, respectively. Odds ratios calculated comparing incidences after each anti-VEGF are 0.78 (bevacizumab versus ranibizumab, p = 0.152), 0.57 (bevacizumab versus pegaptanib, p = 0.227), and 0.73 (ranibizumab versus pegaptanib, p = 0.508). A total of 185 complications were detected (62.16% after bevacizumab). Ocular side-effects registered were 40 cases of sustained intraocular pression (IOP) elevation, one infectious uveitis, one retinal detachment, and one sub-retinal hemorrhage. Other cases were related to transient IOP elevation immediately after injection. Systemic complications registered were one case of nausea, one episode of chest pain with acute vision loss, and one case of acute blood hypertension.

CONCLUSIONS

The majority of significant complications occurred in patients receiving multiple bevacizumab administrations. However, results may be affected by the difference in the utilization amount for each drug. AMD patients were the most represented, probably due to greater indication to treatment.

Presumed pyogenic granuloma associated with intravitreal anti-vascular endothelial growth factor therapy

To report a case of a presumed pyogenic granuloma at the site of multiple intravitreal anti-Vascular Endothelial Growth Factor (VEGF) injections. Intravitreal anti-VEGF injections can be complicated by a localized reaction of the conjunctiva.